Impact of Cocaine Use on Acute Ischemic Stroke Patients: Insights from Nationwide Inpatient Sample in the United States

Cocaine is the third most common substance of abuse after cannabis and alcohol. The use of cocaine as an illicit substance is implicated as a causative factor for multisystem derangements ranging from an acute crisis to chronic complications. Vasospasm is the proposed mechanism behind adverse events resulting from cocaine abuse, acute ischemic strokes (AIS) being one of the few. Our study looked into in-hospital outcomes owing to cocaine use in the large population based study of AIS patients. Using the national inpatient sample (NIS) database from 2014 of United States of America, we identified AIS patients with cocaine use using International Classification of Disease, Ninth Revision (ICD-9) codes. We compared demographics, mortality, in-hospital outcomes and comorbidities between AIS with cocaine use cohort versus AIS without cocaine use cohort. Acute ischemic strokes (AIS) with cocaine group consisted of higher number of older patients (\u3e 85 years) (25.6% versus 18.7%, p \u3c 0.001) and females (52.4% versus 51.0%, p \u3c 0.001). Cocaine cohort had higher incidence of valvular disorders (13.2% versus 9.7%, p \u3c 0.001), venous thromboembolism (3.5% versus 2.6%, p \u3c 0.03), vasculitis (0.9% versus 0.4%, p \u3c 0.003), sudden cardiac death (0.4% versus 0.2%, p \u3c 0.02), epilepsy (10.1% versus 7.4%, p \u3c 0.001) and major depression (13.2% versus 10.7%, p \u3c 0.007). The multivariate logistic regression analysis found cocaine use to be the major risk factor for hospitalization in AIS cohort. In-hospital mortality (odds ratio (OR)= 1.4, 95% confidence interval= 1.1-1.9, p \u3c 0.003) and the disposition to short-term hospitals (odds ratio (OR)= 2.6, 95% confidence interval = 2.1-3.3, p \u3c 0.001) were also higher in cocaine cohort. Venous thromboembolism was observed to be linked with cocaine use (OR= 1.5, 95% confidence interval= 1.0-2.1, p \u3c 0.01) but less severely than vasculitis (OR= 3.0, 95% confidence interval= 1.6-5.8, p \u3c 0.001). Further prospective research is warranted in this direction to improve the outcomes for AIS and lessen the financial burden on the healthcare system of the United States

Concomitant rotator cuff repair and instability surgery provide good patient-reported functional outcomes in patients aged 40 years or older with shoulder dislocation

Background: Recurrent anterior shoulder dislocation in patients aged \u3e /= 40 years is not as rare as once thought. The mechanism of instability in this patient population is different-more likely to be attributed to rotator cuff pathology-compared with that in younger individuals. With an increasingly aging active population, surgical management has a rising role in preventing morbidity associated with recurrent instability. Our purpose was to evaluate outcomes of anterior shoulder instability repair (ie, Bankart or bony Bankart repair) with and without rotator cuff repair (RCR) in patients aged \u3e /= 40 years. Methods: We conducted a retrospective chart review of all patients aged \u3e /= 40 years who underwent surgical repair for anterior shoulder instability from 2008-2016. Patients were categorized into 4 cohorts: Bankart repair only, bony Bankart repair only, Bankart repair with concomitant RCR, and bony Bankart repair with concomitant RCR. Demographic and history-of-instability data were collected. Clinical and functional outcomes assessed included the Single Assessment Numeric Evaluation score, American Shoulder and Elbow Surgeons score, Penn Shoulder Score, visual analog scale score for pain, Western Ontario Shoulder Instability Index score, and patient satisfaction score. Results: A total of 146 patients were included in this study, with 103 patients (71%) having \u3e /=2-year outcome scores. Outcome scores were not significantly different among groups. For patients who underwent Bankart repair only, bony Bankart repair only, Bankart repair with RCR, and bony Bankart repair with RCR, the Single Assessment Numeric Evaluation scores were 80.8 +/- 19.7, 90.0 +/- 10.7, 79.3 +/- 29.4, and 87.2 +/- 10.6, respectively (P = .284); American Shoulder and Elbow Surgeons scores, 83.8 +/- 19.7, 92.4 +/- 17.4, 82.5 +/- 25.6, and 85.6 +/- 12.7, respectively (P = .114); Penn Shoulder Scores for function, 84.5 +/- 17.9, 90.9 +/- 15.3, 83.6 +/- 25.1, and 95.7 +/- 13.0, respectively (P = .286); and Western Ontario Shoulder Instability Index scores, 481.0 +/- 519.5, 292.1 +/- 414.3, 548.9 +/- 690.5, and 320.6 +/- 258.7, respectively (P = .713). Age at the time of surgery significantly differed between cohorts (P \u3c .001). No patients had recurrence of instability during the study period. Conclusion: Similar functional outcomes can be achieved in the surgical management of anterior instability in patients aged \u3e /= 40 years. Rotator cuff tears should be suspected and repaired in patients with anterior instability, especially those aged \u3e /= 50 years

Osseous changes following reverse total shoulder arthroplasty combined with latissimus dorsi transfer: a case series

Background: This is the first report on the incidence of proximal humerus osseous changes and associated clinical consequences in reverse total shoulder arthroplasty combined with a latissimus dorsi tendon transfer (RTSA+LDT). Methods: A multicenter, retrospective review identified all patients who had undergone a primary RTSA+LDT and had at least 3-month radiographic follow-up between 2012 and 2017. Data collection included demographics, oral steroid use, repair technique for LDT fixation, radiographic humeral osseous changes, complications, and need for revision surgery. Results: Twenty-four patients were included with an average age of 70.7 ± 7.9 years and follow-up of 16.3 (3-50) months. Ten patients (41.7%) developed osseous changes at the transfer location. There was no increased risk of developing osseous changes based on the surgical fixation technique (P = .421). Average time to earliest radiographic detection of osseous changes was 2.7 ± 1.7 months, with all changes occurring at or before 6 months. Two patients developed proximal humerus fractures, of which 1 had osseous changes through which the fracture occurred. Discussion: RTSA+LDT may place the proximal humeral cortex at greater risk than previously described. Using a long-stem prosthesis in the setting of RTSA+LDT may limit the consequences of this complication

Comparative Study of Bupivacaine-Fentanyl versus Ropivacaine-Fentanyl for Epidural Analgesia in Labor.

Background Labor pain is one of the most intense pains that a woman experiences. Almost 60% of primiparous women described the pain of uterine contractions as unbearable extremely severe or excruciating. Aims Our study aimed to relieve pain suffering of mother and to decrease fetal acidosis to make the delivery process safer for mother and baby. Settings and Design Thus, epidural labor analgesia was designed comparing ropivacaine-fentanyl (RF) and bupivacaine-fentanyl (BF) as intermittent bolus technique. Materials and Methods Sixty women who requested epidural analgesia having ≥3 cm cervical dilatation were allocated in two groups, one group received RF and the other group received BF. Each group received study drug 16 mL with 50 μg fentanyl and top of 10 mL and 25 μg fentanyl when visual analog scale (VAS) ≥3. The efficacy of analgesia, adverse effects, and obstetric and neonatal outcomes were compared. Statistical Analysis For skewed data or ordered categorical data, nonparametric Mann-Whitney -test was used for statistical analysis of two groups. For categorical data, comparisons were made by Pearson's Chi-square test or Fisher's exact test as appropriate (%). Results Both groups were comparable in terms of demographic data and obstetric and neonatal parameters at the onset of labor Comparison of heart rate, systolic blood pressure (BP), diastolic BP, and saturation between Group RF and Group BF. It was found statistically not significant. VAS score before the epidural study drug was given, was 5 (4-5) in RF group, and was 5 (3-6) in BF group, and after 1 min, VAS score was 1 in both the groups thereafter. The score remained zero till at 100 min in both the groups till the time when the top-up dose was given. Bearing down reflex was present in all the patients as judged by the obstetrician. It was sluggish in 20% of patients in Group RF as compared to 10% in Group BF. Conclusions From clinical and safety perspective, both RF and BF were reasonable choice for labor analgesia

Psychological and social factors that correlate with dyspnea in heart failure.

Dyspnea is a common symptom of heart failure frequently relied upon to assess clinical functioning. The purpose of this study is to explore a broad range of medical, psychological, and social factors that correlate with dyspnea in heart failure patients. Seventy-six participants ranged from well-compensated, ambulatory subjects to those with recent hospitalization for acutely decompensated heart failure. The sample was predominantly male, mean age of 63.5 years, with mild depressive symptoms in 25%. Correlation analysis revealed that dyspnea significantly correlated with depression, fatigue, and overall health perception. Standard regression analyses indicated that depression, fatigue, and overall health perception uniquely contributed to dyspnea, explaining 38.0% of the total variance. The present study confirms that dyspnea is multifactorial, with links to psychological distress and overall health perception

Aggressive Mammary Cancers Lacking Lymphocytic Infiltration Arise in Irradiated Mice and Can Be Prevented by Dietary Intervention.

Because the incidence of breast cancer increases decades after ionizing radiation exposure, aging has been implicated in the evolution of the tumor microenvironment and tumor progression. Here, we investigated radiation-induced carcinogenesis using a model in which the mammary glands of 10-month-old BALB/c mice were transplanted with Trp53-null mammary tissue 3 days after exposure to low doses of sparsely ionizing γ-radiation or densely ionizing particle radiation. Mammary transplants in aged, irradiated hosts gave rise to significantly more tumors that grew more rapidly than those in sham-irradiated mice, with the most pronounced effects seen in mice irradiated with densely ionizing particle radiation. Tumor transcriptomes identified a characteristic immune signature of these aggressive cancers. Consistent with this, fast-growing tumors exhibited an immunosuppressive tumor microenvironment with few infiltrating lymphocytes, abundant immunosuppressive myeloid cells, and high COX-2 and TGFβ. Only irradiated hosts gave rise to tumors lacking cytotoxic CD8+ lymphocytes (defined here as immune desert), which also occurred in younger irradiated hosts. These data suggest that host irradiation may promote immunosuppression. To test this, young chimera mice were fed chow containing a honeybee-derived compound with anti-inflammatory and immunomodulatory properties, caffeic acid phenethyl ester (CAPE). CAPE prevented the detrimental effects of host irradiation on tumor growth rate, immune signature, and immunosuppression. These data indicated that low-dose radiation, particularly densely ionizing exposure of aged mice, promoted more aggressive cancers by suppressing antitumor immunity. Dietary intervention with a nontoxic immunomodulatory agent could prevent systemic effects of radiation that fuel carcinogenesis, supporting the potential of this strategy for cancer prevention